2. Introduction Postoperative complications are the most important factors in determining outcome in the first 72 hours following surgery It is critical to monitor basic physiological parameters such as renal, cardiovascular and respiratory functions

3. Postoperative orders Vital signs Diet: NPO until bowel sounds present Intravenous fluids Care of drains Input and output chart Pain medication: dose and route of administration Antibiotics

4. Postoperative orders Venous thrombosis prophylaxis Other medications

5. Postoperative vascular complications Venous thromboembolism (VTE) includes DVT and PE and are a major but preventable cause of morbidity and mortality

6. Pulmonary embolism Has few definite symptoms But onset of respiratory distress with hypotension, chest pain and cardiac arrhythmias may be harbingers of impending death Can convert a successful operation into a postoperative fatality

7. Prevention of VTE Unfractionated heparin LMWH Graduated compression stockings Intermittent pneumatic compression stockings

8. Risk factors of postop thrombosis Virchow’s triad: hypercoagulability, stasis, trauma to vessels

9. Diagnosis of VTE Venography Impedence plethysmography Doppler ultrasound MRI/MRI Venography

10. Treatment of VTE UFH LMWH

11. Postoperative pulmonary complications Atelectasis Pneumonia Respiratory failure Pulmonary thromboembolic disease

12. Risk factors for PPCs Age > 60 years Cancer Congestive cardiac failure Smoking (within 8 weeks of surgery) Upper abdominal incision Vertical incision Incision length > 20cm

13. Atelectasis Definition not uniform in clinical studies Generally accepted criteria include: impaired oxygenation in a clinical setting where atelectasis is likely Unexplained fever > 38 o C CXR evidence of volume loss or new airspace opacity

14. Risk factors for atelectasis Advanced age Obesity Intraperitoneal atelectasis Prolonged anaesthesia time NG tube placement Smoking

15. Prevention of atelectasis Cessation of smoking (6-8 weeks before surgery) Laporoscopic procedure Deep breathing exercises Mobilization Adequate analgesia (epidural or PCA preferred) Selective gastric decompression

16. Postoperative pneumonia Hospital-acquired pneumonia (HAP) is pneumonia that develops 48 hours or more after hospital admission because of an organism that was not incubating at the time of hospitalization HAP after abdominal surgery increases mortality, hospital stay and hospital charges Caused by a wide range of bacteria. Also by viruses and fungi in immunosuppressed patients

17. Pathogens causing early onset (<4 days) HAP Strep pneumonia MS Staph aureus H influenza E coli K pneumonia Enterobacter spp. Proteus spp. Serratia marcescens

18. Pathogens causing late onset (>5 days) HAP Pseudomonas aeruginosa MDR K pneumonia Acinetobacter spp

19. HAP: clinical definition New opacity on CXR( PA and lat views preferred) plus 2 of the following: Fever >38 o C Leukocytosis or leukopenia Purulent respiratory secretions Diagnosis should be supported by sample of lower resp tract secretions-bronchoscopy

20. HAP treatment Initial therapy should be given IV Combination therapy for those at risk of MDR pathogens Monotherapy for those at low risk of MDR

21. Respiratory failure Def: inability to maintain normal tissue oxygen transport or the normal excretion of carbon dioxide Arterial PO 2 45 mmHg generally indicate significant respiratory compromise Generally managed in ICU including endotracheal intubation

22. Postoperative care of the urinary bladder Most common postop problem of female bladder is atony caused by overdistension and reluctance of the patient to initiate the voluntary phase of voiding Urethral or suprapubic catheter is used 7-10 days postop postvoid residuals are evaluated If >100ml catheterization duration is extended Once residuals are less than 100ml on 2 successive voidings of >200ml catheters can be removed

23. Postoperative GIT managenent Advancing of diets should be individualized Patients with uncomplicated surgery may be given a regular diet on the 1 st POD if bowel sounds are present, if abdominal exam reveals no distention and patient is not nauseated from anaesthesia Seriously ill patients may reuire TPN